News: Article on naloxone in "Small Fixes" section of the NY Times

There has been a lot of attention to opiate overdose prevention and naloxone in the press lately! Here's the latest piece from the New York Times, which makes mention of the fact that it's not only the U.S. that distributes naloxone to drug users - lots of other countries have programs too.

http://www.nytimes.com/2011/09/27/health/27overdose.html?ref=health

Kits Using Naloxone Revive Addicts After Opiate Overdose

By JASCHA HOFFMAN

Next to car crashes, opiate overdoses are the leading cause of accidental death in the United States. In Europe, a lethal overdose occurs every hour. In poorer countries the problem is harder to measure, but in some places it is most likely even worse. When a person overdoses on opiates, his breathing becomes shallow and may eventually stop. Friends may be afraid to call an ambulance for fear of arrest. In remote areas, an ambulance may come too late, after oxygen deprivation has caused brain damage or death. Yet naloxone, a medicine that blocks opiate receptors, can revive even the most catatonic drug users. Used for decades by surgeons and paramedics, the drug has been shown to work when administered by bystanders in American cities. Recently groups in Eastern Europe and Central Asia have been distributing “overdose rescue kits,” which usually contain two doses of naloxone and two syringes. These groups may operate in a legal gray area by training addicts and their families to administer the drug themselves in the event of an overdose. Aside from saving lives, the kits give addicts a reason to return to treatment centers, where they may receive H.I.V. testing or counseling. In China, hot line operators dispatch rescue kits via motorcycle to desperate callers. In Afghanistan, an overdose rescue program relies on the same “skilled injectors” whom addicts pay to shoot them up with heroin. A shot of naloxone runs about $6 in the United States, but in most other countries the cost is below $2 and can be as little as a quarter. Global distribution of the drug as a nasal spray may make the kits even more practical.

Help Us Build a Better Resources Page

You now may notice a new tab in the upper right corner of the site, which offers up a number of resources on overdose prevention and response that we think are helpful. Right now the page includes links to a handful of organizations that are leading the fight against overdose and a selection of training materials, policy documents, and video.


It's a start, but we're missing a lot of good things. So help us build a better resources page by sending your suggestions for content to include and ways to organize the page as a comment to this post or by email to ODPreventionAlliance@gmail.com. Anything and everything is welcome, especially resources in languages other than English.

News: NIH Says Alcohol Poisoning Up in American Youth, Opioids Implicated in 20% of Hospitalizations

The U.S. National Institutes of Health has a new paper out (available here) that reports huge rises in overdose-related hospitalizations among Americans aged 18-24 between 1999-2008, including a 25% increase for alcohol overdose, a 56% increase for drug overdose, a 76% rise for combined alcohol/drug overdose, and a 122% increase in the number of hospitalizations related to prescription opioid overdose. 


Have a look at the press release here. 

News: Naloxone in NYT

For Many, a Life-Saving Drug Out of Reach

By MAIA SZALAVITZ, New York Times, 22 September 2011

An outstanding article on naloxone distribution and a story from Mark Kinzly, a longtime overdose researcher and provider, including a plea for over-the-counter naloxone.

Cocaine, Speed, and “Overdose”: What Should We Be Doing?

By Eliza Wheeler, DOPE Project, Harm Reduction Coalition, San Francisco

This is going to be a two-part post about cocaine and stimulant-related deaths and what harm reductionists can start doing about it. The first part is a rant, the second part is some harm reduction information about stimulants and “overdose” (not the right word, but we’ll get to that), created from a meeting with some folks from the Speed Project here in San Francisco.

The Rant

So, the good news is that we have over 200 places in the U.S. where someone can get naloxone and overdose prevention education, and more are popping up every day. This is a great thing, because we know that opioid-related overdoses (pharmaceuticals and heroin) make up the bulk of overdose deaths in the US. However, according to the CDC’s most recent report, there were 27,658 unintentional drug overdose deaths in the US in 2007 and the second most common drug involved in those deaths, before heroin, was cocaine. According to this report, there were about 12,000 opioid-related deaths and 1,900 heroin deaths—making up the majority. However, there were 5,000 cocaine-related deaths.  I’m sorry, but that’s 5,000 people who died (at least), and I personally think that’s a lot of people.

According to the most recent DAWN report (PDF), here in San Francisco, there were 103 cocaine-related deaths in 2008 and 65 stimulant-related deaths. There were 221 opioid-related deaths. The San Francisco Medical Examiner’s report shows the same thing—the majority of deaths are opioid-related, but following in close second is cocaine. However, cocaine is the most frequently found drug (after alcohol) in people’s system when the Medical Examiner does post-mortem toxicology.  Deaths are not the only issue, however. Stimulants like amphetamine and methamphetamine don’t contribute to a very high number of fatalities on their own, but are mentioned frequently in emergency room admissions and other types of deaths, including homicides, suicides, traumas, vehicular deaths. According to DAWN data, in 2008, cocaine was involved in 482,000 Emergency Department visits—48% of all visits involving illicit drugs. Stimulants, including amphetamines and methamphetamine, were involved in 91,939 ED visits, or 9.3 percent.

My point with the data (and believe me, I know data is flawed and incomplete and never tells the whole story) is that although opioids surely cause the majority of deaths, we have systematically ignored the fact that the second largest number of deaths is attributed to cocaine, not to mention other harms that come from cocaine and stimulant use that land people in the emergency room. By we, I mean harm reduction programs, overdose prevention projects, public health departments—you name it, we’ve done a bad job at addressing cocaine and stimulant-related death and injury.

I have many thoughts on why this is. Part of it is because it’s a more complex issue than opioid overdoses, and there’s no magic bullet like naloxone so people avoid talking about it. Also, cocaine and speed are different, and have different effects on the body, so even within the stimulant category, you need different messages. So are we lazy? Do we not care about cocaine and speed users? What’s our excuse? In my decade of harm reduction work, the most I usually hear in an overdose training is “for stimulants and coke, if they’re having a heart attack do CPR if you know how and call 911, sorry.” Is the harm reduction community (with some wonderful exceptions), shamefully heroin-centric? Is there deeply embedded racism, classism and…drugism (I made that up) effecting how much effort we put into certain aspects of harm reduction work? I think so, considering that in 2011, there are still only a handful of programs that even give out crack pipe covers, and inevitably when someone comes to the exchange tweaked on speed at least one person rolls their eyes and pretends to restock the condoms. The amount of shame and stigma still heaped onto coke and stimulant users is incredible—and I’m talking about just in the harm reduction world.

SO ANYWAY, what do we need? What do we do?

1.  First of all, we need a new word. Overdose is not the right word for what happens with cocaine or speed. Even if it was, it has too strong an association with heroin and other downers. I was talking with a group at the Speed Project in SF recently and I asked “what do you consider an overdose?” and they all said, “It’s what happens when you take too much heroin.” The word that group used to describe the uncomfortable or dangerous effects of taking speed was “overamping.” But what is it called if someone who has been smoking crack for 20 years and dies of a heart attack when they’re walking up the stairs at age 40? Is it an overdose? Not really. But there’s certainly a case to be made that a heart attack at age 40 was highly “influenced” by crack use which we know is very hard on the heart. With stimulants, the problem is not even necessarily dose-related at all. You could overamp on speed on your fourth day of a run because you are dehydrated, malnourished, haven’t slept and your body and mind are just telling you to knock it off. So long story short, like I said, overdose is the wrong word. It’s confusing and inaccurate.

2.  We need more data and research. Actually, we need better interventions and resources, but to get those, you need data and research. As Matt said in his post about “Missing Data,” we need more information on how co-morbidities or other behaviors like smoking affect risk of cocaine-related deaths. I’m curious about the speed-related deaths. What happened? I can never actually find any information on that. In the SF Medical Examiner’s report, it said that a few people died from aneurisms caused by speed. Really? I would like to know a bit more about that, thank you. I called the ME one day, and asked if all of the cocaine-related deaths were from cardiac arrest because I wondered if people also died from fatal seizures or strokes. He laughed at me and told me everyone dies from cardiac arrest. Smart ass. I guess it was a dumb question, but I didn’t know how to ask the question. This is where you researchers come in!

3.  We need to invest the same amount of effort into creating realistic messages around cocaine and speed-related harms that we did with heroin/opioid overdose. This means that drug user involvement in creating interventions for coke and speed users is an obvious necessity. We need to redefine overdose, talk to people about the amazing harm reduction strategies they already use (see part 2 of this post), and develop some real prevention strategies, not just “drink water and get some sleep.”  If we do a better job at treating co-morbidities like high blood pressure, COPD, or cardiovascular disease or offering smoking cessation, could cocaine-related heart attacks decrease?  So, is primary care the answer? Do we invest in educating physicians on how to not treat drug users like crap and to address stimulant-related harms by strengthening the rest of the body? Ah, so many questions.

So in the meantime, while you go figure all of this out, be on the lookout for part 2 of this article, which is a strategy we came up with here in SF to talk about overamping on speed. 

News: Overdose Trends in the USA: More Deaths by Overdose than Traffic Accidents?

The Los Angeles Times has a story up that looks at recent data on overdose deaths in the United States and concludes, among other things, that there are now more fatalities from overdose than form traffic accidents. The basic idea - that there are lots and lots of people dying from overdose and that prescription opioids are responsible for a lot of those deaths - is correct.


Some other aspects of the piece deserve to be read with with a few grains of salt. It's a little unclear how the Times used "preliminary data" from the U.S. Centers for Disease Control and Prevention (CDC) to come up with a purported 37% increase in overdose deaths between 2007 (the year for which CDC most recently reported, at 27,658 deaths) and 2010 (for which the Times estimates 37,485 deaths). Yes the trend has been upward, but I'm going to go out on a limb and say that the figure produced in the article sounds a little wrong.  The article also tends to lean too heavily on scary quotes from law enforcement warning of dire consequences from our "insatiable appetite" for Vicodin and so on, and misses some very interesting data showing major regional differences in overdose mortality. Still, not a terrible article and there's some important information in there.


For a more dispassionate take on recent trends in U.S. drug overdose, it's worth looking at CDC's 2010 issue briefing on "Unintentional Drug Poisoning in the United States." The whole thing is worth reading (and it's only 4 pages), but there are a couple nuggets that strike me as especially interesting. 


One is that while prescription drugs (largely opioids and benzodiazepines, but also other medications used in psychiatry) are now involved in about half of deaths, among illegal drugs cocaine was involved in more than twice as many deaths as heroin, and cocaine deaths have trended upward for the last 10 years. So where's the media attention to cocaine? More importantly, where are good cocaine overdose prevention programs?  Stay tuned, because we'll be looking more into that issue in an upcoming two-part series from the Harm Reduction Coalition's Eliza Wheeler, who runs the DOPE Project in San Francisco. 


Second, there's wide variation among the states. Part of that is due to some big differences in prescribing, but one of the most interesting things is where we see the lowest overdose mortality. For example, in New York and California we see about half the death rate of the states with the highest rates. These also happen to be places that have invested in harm reduction programming, including overdose prevention programs and drug treatment with methadone and buprenorphine. Coincidence? It's probably related to a lot of things, but there sure are a lot of these kinds of coincidences around overdose prevention. 

Embarking on a Cost Analysis of Opioid Overdose Morbidity and Mortality in the U.S.

By Leo Beletsky and Andrea Sorensen

Much attention has been devoted in recent years to the alarming increase in morbidity and mortality related to opioid overdose.  Between 2004 and 2007 there was a nearly fourfold increase in the use of prescription opioids in the US, and in at least five states this is now the leading cause of unintentional injury death.[1]  Data such as the number of emergency room visits and deaths attributable to opioid overdose have raised awareness among states and the federal government that there is much work needed in preventing and addressing this epidemic.

A growing body of research and reports addressing this issue have focused on, for example, the severity of this problem in particular states, the trends of a particular opiate such as methadone[2], or the societal cost of drug addiction more broadly.  Lacking from this literature is an assessment of the overall costs that result from the increased overdose morbidity and mortality.  Thus, we intend to perform a cost-of-illness analysis by assessing the costs associated with emergency room visits, lost productivity due to hospitalization, and costs to society resulting from premature deaths.  Data permitting, we will focus on the annual cost in 2008—the most recent year for which healthcare cost data are available. 

We are currently working to collect data and information from a wide variety of sources in order to provide a national cost estimate and range.  Our costs will include healthcare costs/medical expenses; the economic impact from days of work lost due to hospitalization; and the costs associated with lives lost and premature death.  Thus, we will take into account both direct (medical) and indirect (lost productivity and lost lives) to estimate this annual cost burden.

We are relying on DAWN statistics for Emergency room visit data, which provides a breakdown of the annual number of ER visits attributable to opioid/opiate abuse.  DAWN also provides data for the cost of an average hospital stay for accidental poisoning and substance abuse stays, as well as the average length of stay by condition.  This will allow us to calculate the cost per episode that we can use to determine the entire direct health care cost component.  The average length of hospital stay data will also be used to determine lost productivity due to hospitalization.

Prevalence of premature death will be determined using the National Vital Statistics System data.  We will calculate the premature death costs based on previously established methods used in similar cost analysis research:  we will rely on the value of statistical life (VSL) determined by Aldy and Viscusi (2003)—a value that has been used widely in other similar cost studies.  In addition, we will calculate projected lost earnings based on the number of deaths attributable to opioid overdose in each age group, using life expectancy data and estimated earnings data (for each age group).  International Classification of Diseases (ICD) 10th Revision, T-40.0—T40.6 are of interest for this analysis. The overall category ICD -10 T40 includes Poisoning by narcotics and psychodysleptics (hallucinogens).  We have yet to locate this mortality data.  While there are many summary reports published by the CDC, finding specific breakdowns of mortality causes has proven challenging to pinpoint.  It looks as though the Healthcare Cost and Utilization Project (HCUP) offers databases available for purchase that might contain this information (http://www.hcup-us.ahrq.gov/tech_assist/centdist.jsp).  

Questions that have emerged during our initial stage of gathering data and defining costs include selecting proper ICD categories and determining the accuracy of deaths attributable to prescription opioid overdose, as earlier research has found that death certificates might fail to specify this as the reason of death, thus underestimating the actual number.[3]

Our goal is for this cost analysis to inform policymaking and funding decisions.  Our findings can help state and Federal government agencies and other funders quantify the costs of opioid overdose morbidity and loss of life.  Cost estimation is important for setting priorities in prevention programming, surveillance, and research particularly at a time of particularly scarce public health resources. Quantifying this piece can also provide an important component in future benefit-cost preventative treatment studies. 

---

[1] http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5842a1.htm

[2] http://www.cdc.gov/nchs/data/hestat/poisoning/poisoning.htm

[3] http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5842a1.htm

Pubmed September 2011 Update

Three notable papers this week

Characteristics of drug users who witness many overdoses: Implications for overdose prevention.

Bohnert AS, Tracy M, Galea S. Drug Alcohol Depend. 2011 Aug 10.

Comment: Another analysis from a non-fatal overdose survey in Harlem and the South Bronx. There have been some concerning results in terms of witness management of overdose from this study. We know that those who have overdosed are at higher risk of overdose and from a 2005 analysis also know that they are less likely to contact emergency medical services when they witness an overdose. Now we know that these findings apply to those who witness multiple overdoses as well (they appear to be almost the same population). Authors propose that prior negative experiences with medical service might dissuade contact at future overdoses, although perhaps successful prior lay resuscitation efforts also discourage calling for help.

Drug-Related Death Following Release from Prison: A Brief Review of the Literature with Recommendations for Practice.

Leach D, Oliver P. Curr Drug Abuse Rev. 2011 Aug 12. [Epub ahead of print]

Comment: I don’t have access to the full article and hope that naloxone distribution is discussed as one of the options.

Mortality among Substance-using Mothers in California: A 10-year Prospective Study.

Hser Y, Kagihara J, Huang D, Evans E, Messina N. Addiction. 2011 Aug 10

Comment: Mortality among pregnant or parenting women seeking substance abuse treatment (including heroin, cocaine, alcohol, marijuana, and methamphetamine) over ten years was 8.4x higher than the general population, the largest portion of which was from overdose (29%). The authors do not breakdown overdose by primary drug problem (i.e. can’t tell if most of the overdoses were among heroin users or if they were more evenly distributed).

Missing Data

By Matt Curtis

Looking back to the situation five or ten years ago, we’ve made major progress in building an evidence base around overdose, both in terms of the prevalence of overdose in different kinds of drug using communities and the efficacy of prevention and response programs. More research is happening now than ever before, at a bigger scale and in more places.

A random graph not actually associated with this article

As with any new area that epidemiology sticks its nose into the first wave of research is often all about counting: how big is the problem, what kind of people is it affecting, where and in what way? Although there’s work to be done still on these kinds of most basic questions, we have a pretty good idea of the scale of the overdose problem in many parts of the world and enough solid information to take action at a public health level without fearing we may be wildly off base. (Some people would disagree with that statement, which may deserve a fuller discussion on OPA; for now I’ll only note that doubters of overdose prevention programming are nowadays mostly confined to the wing of public health usually referred to as “Wrong.”)

So what should come next? Here, thinking out loud, are eight areas that I think researchers could fruitfully investigate:

(1) Smoking and cardiovascular and lung disease: How much is tobacco smoking-related cardiovascular disease related to cocaine (and other stimulant) overdose?  Similarly, how much is smoking, COPD, chronic bronchitis and other chronic lung disease related to opioid overdose?  My gut tells me the answer in both cases is ‘probably a lot, especially in combination with other health problems,’ but there’s very little published information on these subjects. And I don’t know a single harm reduction organization that has a serious tobacco harm reduction or smoking cessation program (though that may be just because I need to get out more). Are we failing people on this because everyone’s just thinking that smoking is pretty punk rock and part of the scene and all I need is nic-fitting crack users running around my drop-in center?

International Overdose Awareness Day News and Opinion Roundup

As we mark International Overdose Awareness Day today, there is more attention than ever to the subject and a number of excellent articles online. Here's a quick rundown of some of them:

The amazing New York City organization VOCAL is campaigning for the NY Police Department to   support New York's recent 911 Good Samaritan law by training officers and conducting community outreach. The law, which goes into effect on September 18, will provide protection against arrest or prosecution for illegal drug possession (including alcohol possession for minors) for people who call an ambulance in response to an overdose. Do you live in NYC? You can support VOCAL's campaign here.

The Drug Policy Alliance (DPA) is pushing a similar 911 Good Samaritan bill in California, and has published an open letter to Governor Jerry Brown today. More information on DPA's work on overdose can be found here, including ways to get involved.

OPA editor Roxanne Saucier has an article on the Open Society Foundation's website on the "I'm the Evidence: Naloxone Works" video campaign organized by the Eurasian Harm Reduction Network and the Harm Reduction Coalition. Join the campaign's Facebook page here and have a look at OPA's explanation of how to contribute your own videos.

Music executive and DPA board member Jason Flom has a good op-ed in today's New York Post reflecting on overdose and the music industry. Have a look here. 

The drugs, addiction and recovery magazine The Fix has a story on International Overdose Awareness Day, including links to events happening around the world.

Shawn Norton has a moving story about struggling with her daughter's overdose death and how she came to be involved in overdose prevention advocacy.

What did we miss? Please send OPA more news or your own thoughts on International Overdose Awareness Day and we'll be happy to post them.

At your service: Overdose Q&A from the Thai national overdose training

The Thai AIDS Treatment Action Group (TTAG) recently organized a national overdose training for harm reduction groups in Thailand. Participants raised a number of questions about overdose, some of which were passed on to me by TTAG’s Karyn Kaplan. We thought it made for a nice Q&A, and so we share the results below.  ---Matt Curtis

Karyn Kaplan: There was definitely confusion about the role of CPR in a heroin OD, or a poly-drug OD. They got the breathing-is-essential thing, but does one STOP the breathing to administer CPR and when? Or, never with heroin OD, just do rescue breathing?

Matt and Karyn on the Chao Phraya River in Bangkok

Matt Curtis: The point is that you don't want to do chest compressions on someone who's heart is still doing its job, which will be the case in most heroin/opioid or benzo overdoses. Opioids don't cause the heart to stop; in this case an extended period of oxygen deprivation causes the heart to stop, at which point chest compressions are indicated, but probably not going to help much.

In treating an opioid OD, it's best to focus on airway management, breathing, and naloxone, and even better to do all that plus get the person professional medical attention. I’d say it’s also especially important to focus in on this point in our OD prevention work, like when delivering a short (e.g. 5-10 min) training in a harm reduction setting. If there's time, it's always appropriate to teach people to check the ulnar (wrist) and jugular (neck) pulse, but again I'd stress oxygen always + naloxone if available.

Also, a small nomenclature issue: CPR = rescue breathing + chest compressions, which isn't really the normal recommended standard of care for any situation anymore – see for example the American Heart Association guidelines on rapid chest compression for heart failure, which the Harm Reduction Coalition has nicely summarized specifically in relation to overdose.  

KK: Once naloxone wears off, can you OD again from any residual heroin? There was this question about heroin still being in your body.

MC: Yes. Heroin continues to be metabolized while naloxone is active, but naloxone does not remove heroin from the body. This is why people will generally stop feeling dopesick and potentially high again as naloxone starts wearing off after 30 minutes or so. Although there is risk of OD’ing again after naloxone is administered – and certainly a much greater risk of OD if people use again soon after being revived – in practice this seems to be very rare.

A typical example is from a 2006 paper published out of the Chicago Recovery Alliance overdose project. Among 319 documented overdose reversals with naloxone there were NO cases of re-treatment being needed after the initial dose of naloxone wore off.  And for that matter, there were only five cases where more than one dose of naloxone was needed, two cases of non-withdrawal complications (1 vomiting, 1 seizure), and only one death. Other studies, including ones that have looked for deaths after people were discharged from hospital emergency departments after treatment for heroin overdose, have confirmed the Chicago findings.

All that said, it’s important to promote aftercare, because the risk of going back into OD is real, because there can be other complications of nonfatal overdose, and because it’s just good to take care of people.

Another place for Discussing OD Issues

While not new they have some unique videos there...

Issues In Injecting Drug Use
A BLOG for people implementing projects for people who use drugs

http://issuesinidu.blogspot.com/2010/01/take-home-naloxone.html

or by joining https://psi-org.socialcast.com/groups/injectingdrugusers

Pubmed August 2011 Update

Two notable papers in this report:

1) Characteristics of an Overdose Prevention, Response, and Naloxone Distribution Program in Pittsburgh and Allegheny County, Pennsylvania
Bennett AS, Bell A, Tomedi L, Hulsey EG, Kral AH
J Urban Health. 2011 Jul 20 [Epub]Comments: A substantial contribution to the growing literature evaluating naloxone programs, this paper is a must-read for anyone interested in opioid overdose prevention.

2) Drug overdose deaths --- Florida, 2003-2009
Centers for Disease Control and Prevention
MMWR Morb Mortal Wkly Rep. 2011 Jul 8; 60(26):869-72Comments: Again, oxycodone has arisen as a major source of overdose mortality. The use characteristics that lead to mortality, however, remain unexplained.

Another Great place for Naloxone and Wisdom About it!

Deported migrants struggle to survive in Tijuana

People deported from the U.S. often end up taking refuge in the gritty Tijuana River canals.

In this photo taken June 22, 2011, one man injects a saline solution into another man who is believed to have overdosed on heroin, in hopes of reviving him, in Tijuana, Mexico. The two men live in the Tijuana River canals where many of the people deported from the U.S. end up taking refuge. With no where else to go, the deportees live among drug addicts or people with mental health problems. Emergency medical services came for the man who is believed to have overdosed, but it is unclear if he survived. (AP Photo/Alejandro Cossio).

http://news.yahoo.com/photos/deported-migrants-struggle-to-survive-in-tijuana-1312588328-slideshow/photo-taken-june-22-2011-one-man-injects-photo-043527688.html

Program report: Training family members and loved ones to respond with naloxone

By Stephen Malloy

As you’ve read on this blog, programs that train drug users to respond to opiate overdose with naloxone are expanding across the globe. An important intervention that’s often overlooked, however, is training family members and “carers” - friends, housemates, and loved ones - of drug users to use naloxone. A program in the UK is doing just that, as Stephen Malloy reports:

In July 2009 the National Treatment Agency (NTA) supported a 16 site pilot project, entitled “overdose prevention and naloxone training for families and carers.” The pilot sites, which were spread across England, recruited and trained family members/carers of people at risk of opiate-related overdose death in overdose prevention; signs and symptoms of overdose; and naloxone administration and basic life support techniques. The family member/carer was also supplied with naloxone IF the person at risk of overdose was available to give written or oral consent for the supply to be made.

A new report shows that 495 family members/carers were trained, and at the time of its writing 20 lives had been saved thanks to naloxone use (18) and basic life support (2). These results demonstrate the need a wider circle of family/carers to be engaged around overdose prevention and crucially, be supplied with naloxone.